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Multiple interventions for treating adolescents with substance use disorders have demonstrated efficacy, but most teens do not show an enduring positive response to these treatments. Contingency management (CM)-based strategies provide a promising alternative, and clinical research focused on the development and testing of innovative CM models continues to grow. This article provides information on the principles that underlie CM interventions, key metrics that define their development and implementation, a brief review of studies that have tested these approaches, and some clinical CM tools. As with other interventions to help youth with substance use problems, there is much to learn about CM approaches.

BACKGROUND: Gender is an important factor in understanding cannabis patterns, yet few studies have explored cannabis patterns among gender minority (GM) individuals – particularly among high-risk age groups including young adults. The evolving cannabis market is reshaping typical patterns of cannabis use in the U.S. The combination of these factors warrants increased efforts to examine cannabis practices in gender-diverse samples. METHODS: Online survey participants between 18–34 years (N=2377) from the U.S. provided information on cannabis practices from May – July 2021. Gender differences across several cannabis outcomes (onset, methods of consumption, product potency, frequency, and quantity) were assessed. Bivariate tests and multiple regression models examined associations between gender (cisgender men: n=1020; cisgender women: n=1178; and GM: n=179) and cannabis outcomes adjusting for sociodemographic characteristics. RESULTS: In regression models adjusted for sociodemographic characteristics, GM identity was associated with later age of onset and lower likelihood of daily use compared to cisgender men and women. Identifying as GM or cisgender woman was associated with fewer lifetime methods of consumption and lower plant and concentrate potency usage. CONCLUSIONS: Findings provide initial insights into potential gender differences in cannabis practices from a sample of heavy cannabis users. GM young adults report use patterns indicative of lower risk compared to cisgender men and women in our sample. Future investigations of gender differences in cannabis use that explore specific gender minority categories and that include alternative sampling strategies are needed to better understand differential risks associated with gender.

Purpose The legal landscape of cannabis availability and use in the United States is rapidly changing. As the heterogeneity of cannabis products and methods of use increases, more information is needed on how these changes affect use, especially in vulnerable populations such as youth. Methods A national sample of adolescents aged 14–18 years (N = 2,630) were recruited online through advertisements displayed on Facebook and Instagram to complete a survey on cannabis. The survey assessed patterns of edible use, vaping, and smoking cannabis, and the associations among these administration routes and use of other substances. Results The most frequent and consistent route of cannabis use was smoking (99% lifetime), with substantial numbers reporting vaping (44% lifetime) and edible use (61% lifetime). The majority of those who had experimented with multiple routes of cannabis administration continued to prefer smoking, and the most common pattern of initiation was smoking, followed by edibles and then vaping. In addition to cannabis use, adolescents reported high rates of nicotine use and substantial use of other substances. Adolescents who used more cannabis administration routes tended to also report higher frequency of other substances tried. Conclusions Additional work is needed to determine whether the observed adolescent cannabis administration patterns are similar across different samples and sampling methods as well as how these trends change over time with extended exposure to new products and methods. The combined knowledge gained via diverse sampling strategies will have important implications for the development of regulatory policy and prevention and intervention efforts.

Background Daily cannabis use is increasing in the United States (US). Yet, it is not known whether daily cannabis use is disproportionately common, or whether it has increased differentially over time, by mental health status. This study estimated the prevalence of daily cannabis use among adults in the US with and without past-month serious psychological distress (SPD; measured by the Kessler Psychological Distress Scale (K6)) in 2016 and estimated trends in daily cannabis use by past-30-day SPD status from 2008 to 2016. Methods Data were drawn from adults age 18 and older in the 2008–2016 National Survey on Drug Use and Health (combined total analytic sample n = 356,413). Linear time trends of daily cannabis use, stratified by SPD status, were assessed using logistic regression models with continuous year as the predictor. Results In 2016, past-month daily cannabis use was significantly more common among those with past-month SPD (8.07%), compared to those without past-month SPD (2.66%). Daily cannabis use increased significantly from 2008 to 2016 among those both with and without SPD although use among those with SPD was persistently higher than use among those without SPD over the time period studied. Conclusions Daily cannabis use is significantly more common among persons with serious psychological distress and is increasing in this group, as well as among those without. Given this increase and the high prevalence of cannabis use among those with SPD, it may be important to consider potential consequences of this increased use for those with mental health vulnerabilities.

Tobacco smoking among those seeking treatment for cannabis use disorder (CUD) is common and is a negative predictor of cannabis outcomes. Quitting tobacco may be beneficial for those seeking to quit cannabis use. This initial proof of concept, controlled trial was designed to compare a simultaneous versus sequential tobacco intervention among those seeking treatment for CUD. Sixty-seven adults received either a simultaneous (SIM) or sequential (SEQ) approach to tobacco cessation in the context of outpatient treatment for CUD. A tobacco intervention (TI) that combined web-based counseling with nicotine replacement therapy (NRT) was provided during weeks 1–12 for SIM and was delayed until weeks 13–24 for SEQ. During weeks 1–12, no between-condition significant differences were observed on treatment participation or cannabis use outcomes. The majority of SIM participants initiated TI counseling (62%), 50% made at least one quit attempt and 41% initiated NRT. Interestingly, 39% in SEQ made tobacco quit attempts and 18% initiated NRT on their own before the TI was offered to them. However, only 30% of those in SEQ continued treatment during weeks 13–24, which compromised between-condition comparisons following the TI, but illustrated a potential clinical concern with delaying the TI. Tobacco cessation outcomes generally were poor and did not differ between conditions. This initial controlled trial suggests that addressing tobacco use during CUD treatment is acceptable and generates action towards tobacco cessation. Additional trials testing more intensive TI models may be necessary to identify more efficacious interventions for co-use of cannabis and tobacco.

Introduction Cannabis is the most widely used illicit drug in the U.S. with 19.8 million current users. Population-based data indicate that almost all cannabis users (90%) have a lifetime history of tobacco smoking and the majority (74%) currently smoke tobacco. Among cannabis users, smoking tobacco is associated with increased frequency of cannabis use, increased morbidity, and poorer cannabis cessation outcomes. There is a lack of research, however, focused on addressing cessation of both substances simultaneously. The purpose of the current pilot study was to evaluate the feasibility and acceptability of a multi-component tobacco/cannabis abstinence treatment. Methods Five participants completed Abstinence Reinforcement Therapy, an intervention that included five sessions of cognitive-behavioral telephone counseling for tobacco/cannabis, pharmacotherapy for smoking cessation, and five weeks of mobile contingency management to remain abstinent from tobacco and cannabis. Results Feasibility of recruitment, retention and treatment completion was high. Satisfaction with the treatment was also high. Conclusion Results support the feasibility and acceptability of this approach with dual cannabis and tobacco users and suggest that further research examining the efficacy of this approach is warranted.

Background Alternative methods for consuming cannabis (e.g., vaping and edibles) have become more popular in the wake of U.S. cannabis legalization. Specific provisions of legal cannabis laws (LCL) (e.g., dispensary regulations) may impact the likelihood that youth will use alternative methods and the age at which they first try the method – potentially magnifying or mitigating the developmental harms of cannabis use. Methods This study examined associations between LCL provisions and how youth consume cannabis. An online cannabis use survey was distributed using Facebook advertising, and data were collected from 2630 cannabis-using youth (ages 14–18). U.S. states were coded for LCL status and various LCL provisions. Regression analyses tested associations among lifetime use and age of onset of cannabis vaping and edibles and LCL provisions. Results Longer LCL duration (OR vaping : 2.82, 95% CI: 2.24, 3.55; OR edibles : 3.82, 95% CI: 2.96, 4.94), and higher dispensary density (OR vaping : 2.68, 95% CI: 2.12, 3.38; OR edibles : 3.31, 95% CI: 2.56, 4.26), were related to higher likelihood of trying vaping and edibles. Permitting home cultivation was related to higher likelihood (OR: 1.93, 95% CI: 1.50, 2.48) and younger age of onset (β: −0.30, 95% CI: −0.45, −0.15) of edibles. Conclusion Specific provisions of LCL appear to impact the likelihood, and age at which, youth use alternative methods to consume cannabis. These methods may carry differential risks for initiation and escalation of cannabis use. Understanding associations between LCL provisions and methods of administration can inform the design of effective cannabis regulatory strategies.

Objective The utility of studying substance use during early adolescence depends on how well indicies of lower-level experimentation predict the development of substance use problems. We examined associations between experimental cigarette use at T1, recanting of use 8 months later (T2), and daily smoking at 2 years (T4). Methods Longitudinal telephone survey of 6522 US youth aged 10–14, examining lifetime cigarette smoking (none, just puffing, 1–19, 20–100, >100) and recanting (i.e., reporting lifetime use at T1, denying ever using at T2) as predictors of T4 daily smoking using multivariable logistic regression. Covariates included sociodemographics, friend/family smoking, school performance, and personality characteristics. Results The sample was 51% male, 18% Black, 17% Hispanic, with 70% retained at T2. At T1, 407 (8.9%) adolescents reported some smoking, of whom 85 (20.9%) recanted at T2. At T4, 970 reported any smoking, of whom 88 (9.1%) were daily smokers. Any T1 experimentation identified two-thirds of T4 daily smokers (sensitivity = 66.7%) with a false positive rate of 7.8%. T1 lifetime smoking categories were associated with the following adjusted odds ratios for T4 daily smoking (vs. never smokers): 2.7 for recanters (95% confidence interval 0.82, 8.5), 3.5 for few puffs (1.7, 7.0), 9.6 for 1–19 cigarettes (4.1, 22.3), 3.8 for 20–100 cigarettes (1.0, 14.3), and 30.1 for >100 cigarettes (8.1, 111). Conclusions In this sample experimentation with cigarettes predicted future daily smoking with high utility. The findings provide a rationale for monitoring and reporting any experimentation cigarettes as a tobacco surveillance outcome.

BACKGROUND: Delay Discounting (DD) relates to more frequent cannabis use, but results are variable, potentially because of variations in whether integrated or single-item measures are used, and whether the timeframe of measures is narrow or broad. Explicating the relationship between DD and cannabis use may result from comparing use indices that vary on these characteristics. METHODS: This online study of current cannabis users (n=1,800) assessed DD and three cannabis use frequency items: number of days of use in the past month, times used per day, and weekly-monthly use. A fourth index derived with Latent Class Analysis (LCA) integrated days per month and times per day to try to better characterize frequency patterns. Effect sizes reflecting relations between cannabis use frequency indices and DD were compared. RESULTS: Three frequency classes emerged from the LCA (Low-Moderate-High). DD was significantly associated with times per day (r=.11, d=.21), days of use (r=.09, d=.18), and the LCA index (r=.06, d=.13), but not weekly-monthly use (r=.04, d=.09). Times per day was more strongly related to DD than LCA classes (p

Multiple interventions for treating adolescents with substance use disorders have demonstrated efficacy, but a majority of teens do not show an enduring positive response to these treatments. Contingency management (CM)-based strategies provide a promising alternative, and clinical research focused on the development and testing of innovative CM models continues to grow. This article provides an updated review on the progress made in this area. It is important to continue to search for more effective models, focus on post-treatment maintenance (reduce relapse), and strive for high levels of integrity and fidelity during dissemination efforts to optimize outcomes.

Background Rates of young adult cannabis use are rising, perceived harm is at its historical nadir, and most users do not want to quit. Most studies evaluating effects of cannabis use in young adults are cross-sectional, limiting causal inference. A method to reliably induce abstinence periods in cannabis users would allow assessment of the effects of abstinence and resumption of use on a variety of outcomes in a within-subjects, repeated measures design. Methods We examined the efficacy and feasibility of a voucher-based contingency management procedure for incentivizing one month of continuous cannabis abstinence among young adults who reported at least weekly cannabis use, volunteered to participate in a laboratory study, and did not express a desire to discontinue cannabis use long-term. Continuous cannabis abstinence was reinforced with an escalating incentive schedule, and self-report of abstinence was confirmed by frequent quantitative assays of urine cannabis metabolite (THCCOOH) concentration. New cannabis use during the abstinence period was determined using an established algorithm of change in creatinine-adjusted cannabis metabolite concentrations between study visits. Results Thirty-eight young adults, aged 18–25 years, enrolled and 34 (89.5%) attained biochemically confirmed 30-day abstinence. Among those who attained abstinence, 93.9% resumed regular use within two-weeks of incentive discontinuation. Conclusion Findings support the feasibility and efficacy of contingency management to elicit short-term, continuous cannabis abstinence among young adult, non-treatment seeking, regular cannabis users. Further work should test the effectiveness of this contingency management procedure for cannabis abstinence in periods longer than one month, which may be required to evaluate some effects of abstinence.

Introduction Outpatient treatments for adolescent substance use demonstrate clinically meaningful reductions in substance use, but effect sizes are often low, relapse rates are high, and response to treatment is heterogeneous across participants. The present study utilized cluster analysis to identify subgroups of treatment response among adolescents from three randomized clinical trials evaluating behavioral treatments for substance use. Methods Analyses were performed on a sample of 194 adolescents (average age = 15.8, 81.4% male) who reported cannabis use during the past 30 days or had a cannabis-positive urine test. Clustering was based on percent days cannabis use at 5 time periods (intake, end of treatment, 3, 6, and 9 months post-treatment). Participants in the identified subgroups were then compared across a number of variables not involved in the clustering (e.g., substance use, demographics, and psychopathology) to test for predictors of cluster membership. Results Four clusters were identified based on statistical indices and visual inspection of the resulting cluster profiles: Low Use Responders (n = 109, low baseline level, sustained decrease); High Use Responders (n = 45, high baseline level, sustained decrease); Relapsers (n = 25, medium baseline level, decrease, rapid increase post-treatment); and Non-Responders (n = 15; consistently high level of use). Cannabis dependence, mean cannabis uses per day, and socioeconomic status were predictive of cluster membership. Conclusions Cluster analysis empirically identified different patterns of treatment response over time for adolescent outpatients. Investigating homogenous subgroups of participants provides insight into study outcomes, and variables associated with clusters have potential utility to identify participants that may benefit from more intensive treatment.

Introduction We tested whether environmental cues prompt or inhibit quit or reduction attempts among heavy cannabis users. Methods We recruited 196 daily cannabis users who intended to stop or reduce at some point in the next 3 months. Users called an Interactive Voice Response system daily over 3 months to report on cues that might prompt an attempt to quit or reduce (e.g., a request to stop), cues that might inhibit a quit/reduction attempt (e.g., someone offering cannabis), cannabis use, and attempts to stop or reduce cannabis. No treatment was provided. Results Our major findings were (a) cost and health/psychological problems were the most common prompting cues, and seeing others use and being offered cannabis were the most common inhibiting cues, (b) the number of different types of prompting cues prospectively predicted an increase in attempts to change in a dose-related manner, (c) more proximal cues appeared to be more strongly related to change, (d) requests to stop or reduce, and physical or psychological problems from cannabis, best predicted change attempts, and (e) inhibiting cues did not consistently predict the probability of an attempt to change. Conclusion These preliminary results suggest several environmental cues prompt attempts to change cannabis use. Thus, interventions to increase the frequency of these cues, and specifically requests to stop or reduce cannabis use, and reinforcing concerns about health and mental adverse events from cannabis use, may increase cannabis reduction or cessation.

BACKGROUND: Self-regulation deficits expressed through a decreased ability to value future rewards (delay discounting (DD)) and impaired emotion regulation (negative urgency (NU), cannabis coping motives (CCM), and anxiety sensitivity (AS)) relate to more frequent or problematic cannabis use. However, there is a need to better understand how self-regulation and emotion regulation constructs reflect competition between deliberative and reactive systems that drive individual differences in cannabis use patterns. Further, few studies assess frequency of cannabis use within and across days of use, which may obscure differentiation of individual differences. METHODS: In a large national sample of 2545 cannabis users, Latent Class Analysis was used to derive participant sub-classes based on two frequency indices, self-reported cannabis use days and times cannabis was used per day. Three classes emerged: Low (1–9 days/month, 1 time/day; 23 %), moderate (10–29 days/month, 2–3 times/day; 41 %), and high (30 days/month, ≥4 times/day; 36 %). Relationships among frequency classes and emotional regulation and impulsivity were assessed with a multinomial logistic regression. RESULTS: Higher frequency use was associated with greater DD (χ(2) = 6.0, p = .05), greater CCM (χ(2) = 73.3, p < .001), and lower cognitive AS (χ(2) = 12.1, p = .002), when controlling for demographics, tobacco use, and number of cannabis administration methods. Frequency class and NU were not significantly associated. CONCLUSIONS: Identifying meaningful patterns of cannabis use may improve our understanding of individual differences that increase risk of frequent or problematic cannabis use. Excessive delay discounting and using cannabis to cope with negative affect may be relevant targets for treatments designed to reduce cannabis use.

Driving under the influence of cannabis (DUIC) is a public health concern, and data are needed to develop screening and prevention tools. Measuring the level of intoxication that cannabis users perceive as safe for driving could help stratify DUIC risk. This study tested whether intoxication levels perceived as safe for driving predicted past-month DUIC frequency. Online survey data were collected in 2017 from a national sample of n = 3010 past-month cannabis users with lifetime DUIC (age 18+). Respondents indicated past-month DUIC frequency, typical cannabis intoxication level (1–10 scale), and cannabis intoxication level perceived as safe for driving (0–10 scale). Approximately 24%, 38%, 13%, and 24% of respondents engaged in DUIC on 0, 1–9, 10–19, and 20–30 days respectively in the past month. Among these four DUIC frequency groups, median typical intoxication varied little (5–6), but median intoxication perceived as safe for driving varied widely (3–8). Higher intoxication levels perceived as safe for driving corresponded to frequent DUIC (Spearman's rho: 0.46). For each unit increase in intoxication level perceived as safe for driving, the odds of past-month DUIC increased 18% to 68% (multinomial logistic regression odds ratio - MOR1–9 days: 1.18, 95% CI: 1.13–1.23; MOR10–19 days: 1.40, 95% CI: 1.30–1.50; MOR20–30 days: 1.68, 95% CI: 1.57–1.80). In this targeted sample of past-month cannabis users, DUIC frequency varied widely, but daily/near-daily DUIC was common (24%). Measuring intoxication levels perceived as safe for driving permits delineation of past-month DUIC frequency. This metric has potential as a component of public health prevention tools.

Background Cannabis users frequently report concurrent tobacco use, and tobacco use is associated with poorer outcomes during treatment for cannabis use disorders (CUD). Interventions that simultaneously target both tobacco and cannabis use disorders may enhance cessation outcomes for either or both substances. Methods This study evaluated an intervention integrating highly effective treatments for cannabis and tobacco use disorders. Thirty-two participants meeting diagnostic criteria for CUD and reporting daily tobacco use were enrolled in a 12-week computer-assisted behavioral treatment for CUD. Participants were encouraged to participate in a tobacco intervention that included a computer-assisted behavioral treatment tailored for tobacco and cannabis co-users, and nicotine-replacement therapy (NRT). Cannabis and tobacco outcomes were evaluated using descriptive statistics and were compared to a historical control group that received treatment for CUD but not tobacco. Results Participants achieved 3.6 ± 4.3 consecutive weeks of cannabis abstinence, which was comparable to the historical control group (3.1 ± 4.4). A majority of the sample (78%) completed at least one tobacco module and 44% initiated NRT. Over half (56%) initiated tobacco quit attempts, and 28% were tobacco abstinent for at least two consecutive weeks. Participants showed greater reduction in tobacco use (cigarettes per day) than the historical control group, but differences in tobacco abstinence rates during the final month of treatment were not statistically significant (12.5% vs. 4%). Conclusion Findings suggest that providing a tobacco intervention during treatment for CUD is feasible and may positively impact tobacco use without negatively affecting cannabis use outcomes.

Most of the harm from marijuana use is experienced by daily users. Despite this, there has not been a detailed prospective description of daily marijuana use.We recruited daily marijuana users (n=142) by internet ads, Craigslist, flyers, etc. Participants were mostly women (58%) with a mean age of 33 and 47% were minorities. Participants called an Interactive Voice Response phone system to report marijuana and other drug use daily for 3months.Participants averaged using marijuana 3.2 times per day. Almost all participants used multiple modes of delivery during the study. Bongs/vaporizers/pipes were the most common mode of use (45% of uses). Day-to-day variability in amount of use was relatively small. The median rating of intoxication was 3.8 on a 0-6 scale with no intoxication reported on 1% of days and severe intoxication on 24% of days. The large majority binge drank (71%) or used tobacco (73%). Fifteen during-study variables were associated with the frequency of marijuana use; running out of marijuana and social setting were the strongest correlates. Retrospective reports of "usual" use at study entry were often significantly different than daily reports of use during the study.This is the first detailed prospective description of daily marijuana use. Most users used multiple times/day, used multiple modes to administer marijuana, were often intoxicated, and under-reported high rates of using alcohol and tobacco. The frequency of marijuana use was especially influenced by social factors. These results will help future studies better describe daily marijuana use.

Approximately 50% of individuals seeking treatment for cannabis use disorders (CUD) also smoke tobacco, and tobacco smoking is a predictor of poor outcomes for those in treatment for CUD. Quitting tobacco is associated with long-term abstinence from alcohol and illicit drugs, yet there are no established treatments for CUD that also target tobacco smoking. This report highlights issues related to cannabis and tobacco co-use and discusses potential treatment approaches targeting both substances. Data is shared from the first six participants enrolled in an intervention designed to simultaneously target tobacco use in individuals seeking treatment for CUD. The twelve-week program comprised computer-assisted delivery of Motivational Enhancement Therapy, Cognitive-Behavioral Therapy, and Contingency Management, i.e., abstinence-based incentives for CUD. In addition, participants were encouraged to complete an optional tobacco intervention consisting of nicotine-replacement therapy and computer-assisted delivery of a behavioral treatment tailored for tobacco and cannabis users. All participants completed the cannabis intervention and at least a portion of the tobacco intervention: all completed at least one tobacco computer module (mean = 2.5 modules) and 50% initiated nicotine replacement therapy. Five of six participants achieved abstinence from cannabis. The number of tobacco quit attempts was lower than expected, however all participants attempted to reduce tobacco use during treatment. Simultaneously targeting tobacco during treatment for CUD did not negatively impact cannabis outcomes. Participation in the tobacco intervention was high, but cessation outcomes were poor suggesting that alternative strategies might be needed to more effectively prompt quit attempts and enhance quit rates.

The contracting, prompting and reinforcing (CPR) aftercare intervention has improved treatment adherence and outcomes in a number of clinical trials. In multisite randomized clinical trial 92 graduates of two intensive substance use disorder programs who received CPR were compared to 91 who received standard treatment (STX). The CPR group evidenced increased frequency of aftercare group therapy attendance and near significant findings suggested that more CPR than STX participants completed 3 months (76 vs. 64%), 6 months (48 vs. 35%), and 9 months (35 vs. 22%) of aftercare. However, the groups did not differ on the majority of attendance measures and had similar abstinence rates at the 3-month (67% CPR vs. 71% STX), 6-month (52% CPR vs. 51% STX), and 12-month (the primary outcome measure; 48% CPR vs. 49% STX) follow-up points. Exploratory analyses suggest that CPR might be more effective among participants not required to attend aftercare. The incremental capital and labor cost of CPR compared to STX was $98.25 per participant.

Sleep difficulty is a common symptom of cannabis withdrawal, but little research has objectively measured sleep or explored the effects of hypnotic medication on sleep during cannabis withdrawal.Twenty daily cannabis users completed a within-subject crossover study. Participants alternated between periods of ad libitum cannabis use and short-term cannabis abstinence (3 days). Placebo was administered at bedtime during one abstinence period (withdrawal test) and extended-release zolpidem, a non-benzodiazepine GABA(A) receptor agonist, was administered during the other. Polysomnographic (PSG) sleep architecture measures, subjective ratings, and cognitive performance effects were assessed each day.During the placebo-abstinence period, participants had decreased sleep efficiency, total sleep time, percent time spent in Stage 1 and Stage 2 sleep, REM latency and subjective sleep quality, as well as increased sleep latency and time spent in REM sleep compared with when they were using cannabis. Zolpidem attenuated the effects of abstinence on sleep architecture and normalized sleep efficiency scores, but had no effect on sleep latency. Zolpidem was not associated with any significant side effects or next-day cognitive performance impairments.These data extend prior research that indicates abrupt abstinence from cannabis can lead to clinically significant sleep disruption in daily users. The findings also indicate that sleep disruption associated with cannabis withdrawal can be attenuated by zolpidem, suggesting that hypnotic medications might be useful adjunct pharmacotherapies in the treatment of cannabis use disorders.

The addition of contingency management (CM) to the menu of effective treatments for adolescent substance abuse has generated excitement in the research and treatment communities. CM interventions are based on extensive basic science and clinical research evidence demonstrating that drug use is sensitive to systematically applied consequences. This article provides (a) a review of basic CM principles, (b) implementation guidelines, (c) a review of the clinical CM research targeting adolescent substance abuse, and (d) a discussion of implementation successes and challenges. Although the research base for CM with adolescents is in its infancy, there are multiple reasons for high expectations.

This naturalistic telephone survey study compared perceptions of withdrawal severity in 67 daily cannabis users and 54 daily tobacco cigarette smokers who made quit attempts during the prior 30 days. A Withdrawal Symptom Checklist assessed the severity of abstinence symptoms and a Likert scale assessed perceived relations between abstinence symptoms and relapse. A composite Withdrawal Discomfort Score did not differ significantly between groups (M = 13.0 for cannabis, vs. M = 13.2 for tobacco). Individual symptom severity ratings were also of similar magnitude, except craving and sweating were slightly higher for tobacco. Both groups reported that withdrawal contributed substantially to relapse, and the strength of these ratings was similar across groups. The diverse convenience sample examined in this study adds external validity and generalizability to prior studies that included only users not planning to quit or excluded many common types of cannabis users. The comparable withdrawal experience from these heterogeneous cannabis and tobacco users supports previous findings from controlled laboratory studies and indicates that real-world, frequent cannabis users perceive that withdrawal symptoms negatively affect their desire and ability to quit.

Daily marijuana smokers ( n = 19) who intended to quit or reduce in the next month on their own called a phone each night for 28 nights to report marijuana use and reported intentions to change at the end of each week. Outcomes did not differ between those who initially planned to reduce vs. quit in the next month. Participants averaged three attempts to reduce and one attempt to quit during the 28 days. Participants reduced on 11% and abstained on 14% of days. Most participants were successful in reducing or abstaining on half or more of the days they attempted; however, only four participants (21%) reduced ≥50% for ≥7 consecutive days and only two (10%) abstained for that long. Abstinence or reduction did not appear to change alcohol or caffeine use. We conclude: (a) initial intentions are poor predictors of outcomes, (b) most users make multiple, short-lived attempts to change, (c) reduction was as common as abstinence, (d) many attempts to change are initially successful but few persist, and (e) other drug use does not appear to worsen with marijuana reduction or abstinence.

Background This study assessed whether oral administration of delta-9-tetrahydrocannbinol (THC) effectively suppressed cannabis withdrawal in an outpatient environment. The primary aims were to establish the pharmacological specificity of the withdrawal syndrome and to obtain information relevant to determining the potential use of THC to assist in the treatment of cannabis dependence. Method Eight adult, daily cannabis users who were not seeking treatment participated in a 40-day, within-subject ABACAD study. Participants administered daily doses of placebo, 30 mg (10 mg/tid), or 90 mg (30 mg/tid) oral THC during three, 5-day periods of abstinence from cannabis use separated by 7–9 periods of smoking cannabis as usual. Results Comparison of withdrawal symptoms across conditions indicated that (1) the lower dose of THC reduced withdrawal discomfort, and (2) the higher dose produced additional suppression in withdrawal symptoms such that symptom ratings did not differ from the smoking-as-usual conditions. Minimal adverse effects were associated with either active dose of THC. Conclusions This demonstration of dose-responsivity replicates and extends prior findings of the pharmacological specificity of the cannabis withdrawal syndrome. The efficacy of these doses for suppressing cannabis withdrawal suggests oral THC might be used as an intervention to aid cannabis cessation attempts.

Objective To describe an innovative treatment for adolescent marijuana abuse and provide initial information about its feasibility, acceptability, and potential efficacy. Method Provided an intervention composed of (1) a clinic-administered, abstinence-based incentive program; (2) parent-directed contingency management targeting substance use and conduct problems; (3) a clinic-administered incentive program for parent participation; and (4) individual cognitive-behavioral therapy for adolescents. Data are presented for 19 adolescents, age 15-18 years. Measures of substance use, psychopathology, and parenting were collected before and after the 14-week treatment. Substance use measures were also collected 1 month post-treatment. Substance use was monitored by twice-weekly urine and breath testing. An intent-to-treat model was used. Results Adolescents and parents attended an average of 10.3 and 10.6 of 14 sessions, respectively. Substance use, externalizing behaviors, and negative parenting behaviors decreased by treatment end. Urine testing indicated that abstinence increased from 37% at intake to 74% at treatment end ( z value=2.28, p = .02) and that 53% of adolescents were abstinent 30 days post-treatment. Conclusions Preliminary data provide support for the feasibility and acceptability of a family-based, contingency management model to treat adolescent substance use and conduct problems. Controlled efficacy studies with larger samples are needed.

A valid cannabis withdrawal syndrome has been demonstrated in controlled studies with adult marijuana abusers, yet few published reports have examined cannabis withdrawal among adolescents. Adolescents presenting for outpatient substance abuse treatment, whose primary substance of abuse was cannabis, completed a questionnaire reporting the presence and severity of withdrawal symptoms during past periods of cannabis abstinence. Nearly two-thirds of the sample indicated that they had experienced four or more symptoms, and over one-third reported four or more symptoms that occurred at a moderate or greater severity. The magnitude of withdrawal severity was positively correlated with current emotional and behavioral symptoms and self-reported problems with cannabis use. These findings are consistent with previous studies, though the prevalence and magnitude of withdrawal symptoms were lower than that observed in a similar study with adult treatment seekers [Budney, A.J., Novy, P., Hughes, J.R., 1999. Marijuana withdrawal among adults seeking treatment for marijuana dependence. Addiction 94, 1311-1322]. Further research is needed to elucidate associations between cannabis withdrawal effects, the initiation of cessation attempts, and relapse.

Purpose: Among marijuana-dependent individuals, approximately 50% smoke tobacco. These individuals are exposed to increased risks of respiratory and other health problems. The current study examined whether tobacco smoking among marijuana-dependent individuals is also associated with increased psychosocial and substance abuse problems. Methods: Marijuana-dependent individuals ( N =174) seeking treatment for marijuana problems completed a 2–3 h assessment. Current tobacco smokers were compared to ex-smokers and never smokers on demographic, psychosocial, and substance use characteristics, and treatment outcome. In addition to univariate comparisons, multivariate analyses using multinomial logistic regression were conducted to control for the correlated nature of the predictor variables. Results: Current tobacco smokers earned less income and reported histories of more alcohol problems than never smokers and had fewer years of education, more legal problems, more psychiatric symptoms, and an earlier age of marijuana initiation than ex- and never smokers. Over the course of treatment, current tobacco smokers had significantly fewer marijuana-negative urine specimens and fewer weeks of continuous marijuana abstinence than ex-smokers. Implications: Current tobacco smokers appear to represent a subgroup of marijuana-dependent individuals who have increased psychosocial problems compared to ex- and never smokers and may not respond as well to treatment than ex-smokers.

Discoveries concerning an endogenous cannabinoid system and observations of dramatic increases in marijuana use among youth in the United States have fueled a recent increase in basic and clinical research to better understand and treat marijuana dependence. At the annual meeting of the College on Problems of Drug Dependence (Puerto Rico, 1996) a symposium 'Marijuana Use: Basic Mechanisms, Epidemiology, and Clinical Issues' reviewed a number of important areas of ongoing research that address marijuana dependence. Overviews and original research were presented regarding the development of dependence (preclinical and clinical research), motivational effects (laboratory models), the epidemiology of dependence and its development, clinical management of marijuana use among patients seeking treatment for other drugs of abuse, and treatment for adult marijuana dependence. This paper summarizes the symposium presentations and provides discussion of recent scientific developments concerning marijuana use and dependence.

Cigarette smoking (n = 156) and non-smoking (n = 43) individuals seeking out-patient treatment for cocaine-dependence were compared on demographic, drug use and other variables. Smokers were younger, less educated, earned less money, began cocaine use at an earlier age, used cocaine more frequently, were more likely to inject or smoke cocaine, were more likely to report legal troubles and having harmed someone physically as consequences of their cocaine use, and had more severe employment and legal problems than non-smokers as measured by the Addiction Severity Index. Smoking remained a significant predictor of more frequent cocaine use, using more grams of cocaine per week and using cocaine via an injection or smoking route even after adjusting for demographic differences between smokers and non-smokers via regression analyses. Smoking status was not significantly related to treatment outcome. Overall, these results indicate that cocaine-dependent smokers represent a more high-risk group than non-smokers. This relationship between smoking, cocaine use, and associated problems merits further investigation.

Index Medicus (1966-1990) was searched to quantify and characterize the scientific/clinical community's responses to the cocaine epidemic. The rate of growth in the cocaine literature was compared with the rate of growth in the heroin and marijuana literatures in the 1960s and 1970s. Articles on cocaine increased dramatically over the past 7 years suggesting a clear response from the scientific/clinical community to the public health problems presented by the cocaine epidemic. That literature spans a wide range of areas addressing many scientific and health-care issues. This increase in cocaine citations is similar to that which occurred previously in response to use of heroin and marijuana.

Objective The aim of this study was to conduct a randomized test comparing 2 multicomponent, contingency management interventions, 1 with and 1 without a full parent training curriculum, and an individual treatment for adolescent cannabis use disorders. Method A total of 153 adolescents who met DSM-IV criteria for cannabis abuse or dependence were randomized to motivational enhancement therapy/cognitive-behavioral therapy (MET/CBT), MET/CBT+abstinence-based contingency management (CM), or MET/CBT+CM+Parent Training (PT). Results Overall, during treatment, abstinence was greater for youth receiving clinic- and home-based CM without PT compared to those who received individual MET/CBT. There was no additional benefit of the full PT curriculum on marijuana use, youth externalizing problems, or parenting. Conclusion These results suggest that clinic- plus home-based CM for cannabis use disorders can increase rates of abstinence during treatment over and above an evidence-based treatment (individual MET/CBT), but in this study the addition of a comprehensive parenting training curriculum did not further enhance efficacy. Clinical trial registration information Treatment for Adolescent Marijuana Abuse; http://clinicaltrials.gov; NCT00580671.

Objective Many adolescents with substance use problems show poor response to evidence-based treatments. Treatment outcome has been associated with individual differences in impulsive decision making as reflected by delay discounting (DD) rates (preference for immediate rewards). Adolescents with higher rates of DD were expected to show greater neural activation in brain regions mediating impulsive/habitual behavioral choices and less activation in regions mediating reflective/executive behavioral choices. Method Thirty adolescents being treated for substance abuse completed a DD task optimized to balance choices of immediate versus delayed rewards, and a control condition accounted for activation during magnitude valuation. A group independent component analysis on functional magnetic resonance imaging time courses identified neural networks engaged during DD. Network activity was correlated with individual differences in discounting rate. Results Higher discounting rates were associated with diminished engagement of an executive attention control network involving the dorsolateral prefrontal cortex, dorsomedial prefrontal cortex, inferior parietal cortex, cingulate cortex, and precuneus. Higher discounting rates also were associated with less deactivation in a "bottom-up" reward valuation network involving the amygdala, hippocampus, insula, and ventromedial prefrontal cortex. These 2 networks were significantly negatively correlated. Conclusions Results support relations between competing executive and reward valuation neural networks and temporal decision making, an important, potentially modifiable risk factor relevant for the prevention and treatment of adolescent substance abuse. Clinical trial registration information—The Neuroeconomics of Behavioral Therapies for Adolescent Substance Abuse, http://clinicaltrials.gov/, NCT01093898.

CPDD Membership Committee: Thomas H. Kelly *, Alan J. Budney , Mark K. Greenwald , Annette E. Fleckenstein , Margaret Haney , Dorothy K. Hatsukami f,1 a Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY 40536 USA b Department of Psychiatry, University of Vermont, S. Burlington, VT 05403 USA c Department of Psychiatry & Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI 48207 USA d Department of Pharmacology & Toxicology, University of Utah, Salt Lake City, UT 84112 USA e Department of Psychiatry, NYSPI/Columbia University, New York, NY 10032 USA f Drug and Alcohol Dependence 72 (2003) 97 /98